Measles, Papua New Guinea and the brain

You may not have realised that - since most people nowadays have been vaccinated against it and have never seen it - but measles is a very serious illness. Generally an acute disease of children, measles is spread by the measles virus where it infects the body via the respiratory route and establishes a systemic infection - involving multiple organ systems - via your bodies own immune cells leading to the typical rash, mild to severe respiratory distress and immunosuppression (Rima and Duprex 2006).

[caption id="" align="aligncenter" width="463" caption="Measles virus replicative cycle"][/caption]

In the 'developed' world we tend not to think about infectious disease in the same way as people in other parts of the world; national vaccination campaigns have largely removed the threat (not considering some minor outbreaks) of the some of the biggest human killers and we no longer worry ourselves over whether a family member will come down with these diseases.

Subacute Sclerosing Panencephalitis or SSPE is one of the most serious complications of measles resulting from viral infection of the central nervous system; SSPE is rare (1 in 10,000-25,000 measles infections) but is almost always fatal. Following infection at a particularly young age and on average 8 years following acute infection, a progressive deterioration of neurological function presents : loss of attention span, uncontrolled movements, behavioural changes, cognitive impairment and in all cases vegetative state is entered and death occurs.

It is caused by persistent measles infection i.e one that the isn't removed when your immune system kicks in, which spreads throughout the  cells found within the brain causing cell death and inflammation. Strangely, no infectious virus can be recovered from infected brains and when this was investigated further they found that many mutations occurred throughout the genome rendering many of the genes nonfunctional. Although the major replicative functions (replication and gene expression) were left intact, the genes required for normal particles formation were those mutated suggesting that the virus may exploit the unique cellular environment in the CNS to spread, replicate and survive.

[caption id="" align="aligncenter" width="402" caption="Green Fluorescent Protein expressing measles virus infection of neuronal cell"][/caption]

As I mentioned previously, due to increased transmission of virus, poverty and poor nutrition, measles infection is extremely serious in developing countries and it is no surprise that SSPE occurs here in higher numbers. In Papua New Guinea there exists a very high incidence of SSPE, THE highest incidence - roughly 3 - 20 times as many cases are reported (98 per million people versus 5 per million people). Manning et al (2011) have attempted to further characterise SSPE behaviour in this country between 1997 and 2008 and highlights the significant burden that measles is in many developing countries. They measured SSPE incidence, measles infection rates and time of birth of each patient presenting with SSPE finding a direct correlation between time of birth, measles epidemics and presenting with SSPE. The group emphasises the requirement

Why is SSPE incidence so high here and what can we do about it? SSPE rates are linked to measles infections in a population and hence have been significantly reduced following measles vaccination campaigns. Sadly, only half of children in Papua New Guinea receive two measles vaccines prior to 1st birthday - not enough to sufficiently protect an individual nor a population from measles infection and hence SSPE; there is insufficiently low-level of herd immunity in regions such as papua New Guinea. The level of vaccine effectiveness of measles vaccine in this region is also particularly low - possibly reflecting damage to the vaccine from cold-chain disruption (in tropical climates it is difficult to keep vaccines refrigerated), population genetic effects or persistence of low-level non-neutralising maternal antibody.

We can no longer afford to ignore the importance of measles in developing countries like Papua New Guinea and we must stress the need for adequate vaccine effectiveness and coverage in already susceptible human populations. Studies like these with SSPE emphasise the real-world need for the investigation of the molecular mechanisms of measles virus persistence and we should look forward to a time when we can adequatly treat measles CNS complications - or maybe with better vaccination coverage we may not have to worry about this.

Manning, L., Laman, M., Edoni, H., Mueller, I., Karunajeewa, H., Smith, D., Hwaiwhanje, I., Siba, P., & Davis, T. (2011). Subacute Sclerosing Panencephalitis in Papua New Guinean Children: The Cost of Continuing Inadequate Measles Vaccine Coverage PLoS Neglected Tropical Diseases, 5 (1) DOI: 10.1371/journal.pntd.0000932

Rima, B., & Duprex, W. (2006). Morbilliviruses and human disease The Journal of Pathology, 208 (2), 199-214 DOI: 10.1002/path.1873